The nurse is caring for a client who has become increasingly agitated. He is pacing in the hallway and shouting at other clients. What is the priority action of the nurse?
Attempt to deescalate the client.
Continue to observe the client for increased agitation.
Offer medications to help the client control behavior.
Ensure safety in the environment for the client and others.
The Correct Answer is D
A. Attempting to deescalate the client is important, but ensuring immediate safety is the top priority.
B. Continuing to observe the client may lead to a further escalation of the situation. Safety measures should be taken first.
C. While offering medications may be necessary, ensuring safety is the immediate priority before any interventions are implemented.
D. Ensuring the safety of the client and others is the priority in situations of escalating agitation.
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Related Questions
Correct Answer is C
Explanation
A) Incorrect. Isolating the client in his room may escalate the situation or make the client feel isolated and misunderstood.
B) Incorrect. Asking the client to stop talking may be perceived as confrontational and could potentially agitate the client further.
C) Correct. Speaking slowly and in a quiet voice can help the client focus and may reduce the flight of ideas. This calm approach can be grounding for the client.
D) Incorrect. Encouraging the client to talk more may exacerbate the flight of ideas and the manic state.
Correct Answer is A
Explanation
A. Increase your fluid and fiber intake to prevent constipation – Risperidone, an atypical antipsychotic, can cause constipation due to its anticholinergic effects. Increasing fluid and fiber intake can help prevent this.
B. Have your blood pressure checked frequently for hypertension – Risperidone is more commonly associated with orthostatic hypotension, not hypertension.
C. Expect to have your blood checked weekly for serum electrolyte imbalances – Unlike clozapine, risperidone does not require frequent blood monitoring for electrolyte imbalances.
D. Increase caloric intake to prevent weight loss – Risperidone is more likely to cause weight gain rather than weight loss, so increasing caloric intake is unnecessary.
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